Third Party Reimbursement and Risk Management
Phillip L. Sims, Instructor
23 May through 13 July 2005
Monday and Wednesday, 1940 to 2210 hours
Fort Bliss, Texas
I. COURSE DESCRIPTION
Public and private insurance, case management, preferred provider organizations,
health maintenance organizations, and other forms of third party payment for
health care services. Loss prevention for the health care organization through risk
management and cost containment.
II. GOALS OF THE COURSE
The course is designed so that the student will have a better understanding in and of
the role health insurance has in the shaping of services provided by institutions and
physicians. The course will cover a wide variety of subjects dealing with prepaid
health plans, risk management, risk management in health care institutions and loss
III. LEARNING OBJECTIVES
To provide an overview of the history, evolution, and development of health
insurance programs geared toward individuals and groups. Strategic approaches
to risk exposure and management in health care environments.
IV. COURSE ARRANGEMENTS
Lecture / conference Lecture review
Research paper Research presentation
Examination (mid-term) Final Examination
V. COURSE REQUIREMENTS
Paper. A paper will be required of all students. The paper will be at least seven (7)
pages long, not including the index (table of contents) and bibliography, typed and
double spaced. The paper will deal with a subject in relation to the course and
agreed upon between the student and the instructor.
Paper presentation. Each student will prepare a 3 to 5 minute oral presentation
that will provide an overview of the paper the student researched on a subject
dealing with health insurance or risk management. These research papers will be
presented during class with specific dates and times to be discussed in class.
VI. COURSE TEXT
Principles of Risk Management and Insurance, 9th Edition, G. Rejda, Addison-
Wesley Publications, 1998
VII. SUPPLEMENTAL RESOURCES
Risk Management in Health Care Institutions, A Strategic Approach, 2nd Edition
F. Kavaler, MD & A. Spiegel, PhD, Jones and Bartlett Publications, 2003.
VIII. CLASS MEETING AND EXAMINATION SCHEDULE
5-23 Administrative announcements, discussion of the syllabus, lecture/discussion on
history and types of health insurance. Chapters 1 & 2, Risk in our society.
Insurance and risk.
5-25 Discuss Chapter 3. Risk management
5-30 Discuss Chapters 4 and 5. Fundamental legal principles. Analysis of insurance
6-1 Risk management dynamics (Handouts). Risk management activities. Specific
risk management functions.
6-6 Discuss Chapter 7. The liability risk. (Handouts) Identifying and controlling risks
as an employer. Financing of risk and insurance.
6-7 (Handouts) Patient/consumer communications to reduce risk. Ethical issues for
6-13 Discuss Chapters 11. Automobile insurance and society. (Handouts). Assuring
safety and security in health care institutions.
6-15 Mid-term Examination, Chapters 1 through 5, chapter 7, 11, and handouts.
6-20 Discuss Chapters 16, 17 and 21 Fundamentals of life insurance, types of life
insurance and annuities. Individual health insurance coverage.
6-22 (Handouts) Total quality management, continuous quality process improvement,
and evaluation of the risk management program. Student presentations.
6-27 Discuss Chapters 22, 23, and 24. Group life and health insurance. Retirement
plans. Social insurance, Medicares DRG’s. Student presentations.
6-28 (Handouts). Strategies to reduce liability, managing physicians and litigation. Student presentations.
7-4 (Handouts) Identifying and controlling risks in long term care: nursing homes
and home health care. Student presentations.
7-5 Discuss Chapter 28. Government regulation of insurance. (Handouts). Risk
management in managed care organizations. Student presentations. Review for final examination. Chapters 16, 17, 21 through 24, 28.
7-11 Final examination.
7-13 Review of final examination. Make-up student presentations.
IX. CLASS POLICIES
Students are expected to come to all classes and be on time. Roll will be checked . at each class meeting. Classes missed for legitimate reasons, such as illness,
temporary duty, are excusable; however, the student must make up the missed
work. The student is responsible for providing the instructor with justification for
an excused absence either prior to or immediately after the absence. Two un-
excused absences are excessive and three unexcused absences will result in an
involuntary withdrawal and a grade of “F” (attendance) for the course
X. ACADEMIC HONESTY
Submitting someone else’s work as your own will not be tolerated. If determined
by the instructor that academic dishonesty has occurred in any part of the course,
the student(s) involved will normally be given an immediate grade of F and
dropped from the course. The second violation results in automatic expulsion
from the school. The Assistant Vice President will be notified in writing of the
XI. GRADING POLICY
The final course grade will be determined using the following measurements:
Mid-term Exam 30%
Final Exam 30%
Comprehensive Cases (Paper) 35%
Research Presentation 5%
Mid-term exam will cover Chapters 1 through 5, 7 and 11 plus handouts. Final
Exam Chapters 16, 17, 21 through 24, 28, plus handouts.
The comprehensive case (paper) must be typewritten and submitted at the last
lecture prior to the final examination unless previously coordinated with the
instructor. Late papers will be marked down accordingly and a failing grade
assigned if not submitted before the final examination.
The following will be used to assign course letter grades:
90 - 100 A
80 - 89 B
70 - 79 C
60 - 69 D
Below 60 F (for three or more unexcused absences)